Personal Information Form

After completion of this form you will be able to schedule an appointment.

Title *

Gender *

First Name *

Middle Name

Last Name *Please use name as per Medicare

Preferred Name

Date of Birth *

Mobile Number *no spaces please e.g. 0432123123

Email Address *

Have you had an appointment with Highgate Health in last 4 weeks? *

Yes NoNot Sure

Home address *Street address line 2

Suburb *

State *

Postcode *

Do you have Medicare Card? *

YesNo

Medicare card number *

What number are you on the card? *

Iron Infusions at Highgate Health

Please note Iron Infusions do not have an item number for medicare billing therefore no rebate is available

In order to provide Iron Infusions we require:

1. Recent blood results (last three months)
2. The Iron Medication

We DO NOT need a referral

We offer the following options :

Option 1. Just the iron Infusions (Cost $150.00) - you will need to collect the iron medication from chemist before hand

Option 2. If you have recent blood results but do not have a prescription we can offer a bulk billed teleconsult and then you can collect iron form the chemist before the infusion

Option 3. Full service - You turn up to the appointment with recent blood results and we supply the iron and provide the Infusions

Iron cost with Medicare (PBS) $31.60 (without Medicare the cost is $300.00)
Iron Infusion - $150.00
Service fee - - $25.00
Total cost - $206.60

Please select which options you would like

Please select from one of the below *

Option 1 - I have the Iron medication and recent blood results.Option 2 - I would like Highgate Health provide bulk billed Teleconsult and then I will collect the iron from the pharmacy before my infusions Option 3- I have recent blood results but would like like Highgate Health to supply the iron and the infusion

I will bring the medication to my appointment? *

YesNo

We offer a range of Wellness infusions please see Menu here

Please note all Infusions apart from Hydrate require a telephone consult before booking if you have not seen Highgate Health before.

Have you had a consultation with Highgate Health before *

YesNo

Have you been to Highgate Health before for an Intralipid Infusion *

Yes No

Have you ever had Intralipid before? *

YesNo

When was you last Intralipid Infusion?

Did you have any side affects? *

Day 3 or Day 5 Blastocyte ? *

Day 3Day 5

How many IVF Cycles have you had?

Date of pregnancy test?

Who is your GP

Who is your IVF Specialist?

Who is your Obstetrician?

Which hospital do you plan to deliver at?

Which Treatment Protocol ?

BondiLOLAOther

How often are your infusions?

What volume of intralipid are you after?

500mls200mls100mls

Do you have any allergies ?

What medications do you take?

What Vitamin supplements do you take? (details)

Do you take any of the following medication?

ClexanePrednisoloneProgestrogne

Please provide any documentation from your specialist or GP that you have been prescribed this treatment.

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What kind of appointment are you after *

Initial consult with Highgate Health - $155 long consult @40 mins. Where we will obtain a full clinical history and recommended next steps Follow up consult with Highgate Health - $80.00 @ 20 mins. To track how you are going and issue repeat scripts

Are you after a Long Consult or Short Consult *

Short Consult Under 20 Mins ($80) - for repeat prescription or for one medical conditionLong Consult 40 Mins ($155)

Please complete the below form and we will contact you within one business day alternatively please call on on 1300 067 676 for assistance.

Do you wish to provide any further information or documents

NoYes

Please provide further information what would like assistance with? *

Please feel free to upload any other documents e.g. referral or blood results

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I have read and agree to the :

Medical Practice Privacy and Telehealth Consent Form

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Now to schedule the appointment.

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